integrated treatment for dual disorders kim mueser, ph.d. dartmouth medical school nh-dartmouth...
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Integrated Treatment Integrated Treatment for Dual Disordersfor Dual Disorders
Kim Mueser, Ph.D.Dartmouth Medical School
NH-Dartmouth Psychiatric Research Center
OverviewOverview
• Epidemiology• Why focus on dual disorders?• Models of etiology• Assessment• Treatment principles• Research• Avoiding the blame/demoralization trap
Any Substance Use Disorder
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Prev
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ubst
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Gen.Pop Schiz BPD MD OCD Phobia PD
Rates of Lifetime Substance Use Disorder (SUD) Rates of Lifetime Substance Use Disorder (SUD) among Recently Admitted Psychiatric Inpatients among Recently Admitted Psychiatric Inpatients
(N=325) (Mueser et al., 2000)(N=325) (Mueser et al., 2000)
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Schizophrenia Schizoaffective Disorder Bipolar Disorder Major Depression
Factors Influencing Factors Influencing Prevalence of Substance Prevalence of Substance
Use Disorders (SUD): Use Disorders (SUD): Client CharacteristicsClient Characteristics
Higher RatesHigher Rates• Males• Younger• Lower education• Single or never
married• Good premorbid
functioning
• History of childhood conduct disorder
• Antisocial personality disorder
• Higher affective symptoms
• Family history SUD
Factors Influencing Factors Influencing Prevalence of Substance Prevalence of Substance Use Disorders: Sampling Use Disorders: Sampling
LocationLocation
Higher RatesHigher Rates• Emergency rooms• Acute psychiatric
hospitals• Jails
• Homeless• Urban setting
(drugs)• Rural setting
(alcohol)
Major Subgroups of Major Subgroups of Comorbid ClientsComorbid Clients
• Severely mentally ill - psychotic Frequently abuse moderate amounts of
substances Small amounts of substance use trigger
negative consequences
• Anxiety and/or depression Substance use can cause or worsen
symptoms
Frequently abuse moderate to high amounts of substances
• Personality Disorders Antisocial & borderline most common Frequently abuse high amounts of
substances
Clinical EpidemiologyClinical Epidemiology
11. . Rates higher for people in treatment
22.. Approximately 50% lifetime, 25% 35% current substance abuse
33.. Rates are higher in acute care, institutional, shelter, and emergency settings
44.. Substance abuse is often missed in mental health settings
Why Focus on Dual Why Focus on Dual Disorders?Disorders?
11.. Substance abuse is the most common co-occurring disorder in persons with severemental disorders
22.. Significant negative outcomes related to substance abuse:
1) Clinical relapse & rehospitalization2) Demoralization
3) Family stress
4) Violent behavior
1) Incarceration2) Homelessness3) Suicide 4) Medical illness 5) Infections diseases6) Early mortality
3.3. Outcomes improve when substance abuse remits
4.4. Poor treatment is expensive for families and society
Reasons for High Reasons for High Comorbidity Rates of Severe Comorbidity Rates of Severe Mental Illness and Substance Mental Illness and Substance
AbuseAbuse• Berkson’s Fallacy• Self-medication*• Super-sensitivity to effects of
substances*• Socialization motives• Precipitation of psychosis from
substance use
• Common factors Poverty/deprivation Neurocognitive impairment Conduct disorder/antisocial
personality disorder
Self-MedicationSelf-Medication:: More symptomatic clients don’t abuse
more substances Substance selection unrelated to type of
symptoms experienced Types of substances abused unrelated to
psychiatric diagnosis Self-medication may contribute to some
comorbidity but doesn’t explain all More evidence supporting self-medication
in anxiety disorders (PTSD)
Super-sensitivity ModelSuper-sensitivity Model:: Biological sensitivity increases vulnerability to
effects of substances Smaller amounts of substances result in
problems “Normal” substance use is problematic for
clients with severe mental illness but not in general population
Sensitivity to substances, rather than high amounts of use, makes many clients with mental illness different from general population
Stress-Vulnerability ModelStress-Vulnerability Model
BiologicalVulnerability
SubstanceAbuse
Medication Stress Coping
Severityof SMI
Status of Moderate Drinkers Status of Moderate Drinkers with Schizophrenia 4 - 7 Years with Schizophrenia 4 - 7 Years
Later (N=45)Later (N=45)
55.6
20.0 24.4
0%
20%
40%
60%
80%
100%
Abstinent ModerateDrinker
AlcoholUse
Disorder
Source: Drake & Wallach (1993)
Support for Super-sensitivity ModelSupport for Super-sensitivity Model:: Dual disorder clients less likely to develop physical
dependence on substances Standard measures of substance abuse are less
sensitive in clients with severe mental illness Clients are more sensitive to effects of small
amounts of substances Few clients are able to sustain “moderate” use
without impairment Super-sensitivity accounts for some increased
comorbidity
Overview of Assessment Overview of Assessment of Substance Abuse in of Substance Abuse in
Clients with Severe Clients with Severe Mental IllnessMental Illness
Detection
Classification
Functional Assessment
Functional Analysis
Treatment Planning
• Psychological DependencePsychological Dependence - - Use of more substance than intended, unsuccessful attempts to cut down, giving up important activities to use substances, or spending lots of time obtaining substances.
• Physical DependencePhysical Dependence - - Development of tolerance to effects of substance, withdrawal symptoms following cessation of substance use, use of
substance to decrease withdrawal symptoms.
Functional AssessmentFunctional Assessment• GoalsGoals:: To understand client’s functioning
across different domains and to gather information about substance use behavior
• Domains of FunctioningDomains of Functioning
1. 1. Psychiatric disorder
2.2. Physical health
3.3. Psychosocial adjustment (family & social relationships, leisure, work, education, finances, legal problems, spirituality)
• Dimensions of Substance AbuseDimensions of Substance Abuse1.1. 6-Month Time-Line Follow-Back
Calendar2.2. Substances abused & route of administration3.3. Patterns of use4.4. Situations in which abuse occurs5.5. Reported motives for use
• Social• Coping• Recreational• Structure/sense of purpose
6.6. Consequences of use
Evaluating Social FactorsEvaluating Social FactorsAssociated with Associated with
Substance AbuseSubstance Abuse• Does person have non-substance abusing
peers?• Can person resist offers to use substances?• Is the person lonely?• Can the person initiate and maintain
conversations?• Is person able to get others to respond
positively to him/her?• Can the person express feelings? Resolve
conflicts?
Common Symptoms Common Symptoms AssociatedAssociated
with Self-Medicationwith Self-Medication
• Depression, suicidal thoughts• Anxiety, nervousness, tension• Hallucinations• Delusions of reference & paranoia• Sleep disturbance• Mania/hypomania
Recreational Skills and Recreational Skills and Substance AbuseSubstance Abuse
• What does the person do for fun?• Hobbies?• Sports?• What is person’s involvement with
others in recreational activities?• Does the person not participate in
activities which he/she previously did?
Functional AnalysisFunctional Analysis• GoalGoal:: To identify factors which influence or control
substance use behavior• Characteristics of Useful Functional AnalysesCharacteristics of Useful Functional Analyses
1. 1. Focus on behaviors, NOT stable traits2.2. Constructive, NOT eliminative3.3. Contextual, NOT mechanistic4. 4. Examines maintaining factors, NOT etiological
factors5.5. Leads to hypotheses that can be tested by
treatment & modified, NOT theories that remain unchanged regardless of outcome
6.6. Change usually doesn’t happen magically on its own
•Constructing a Payoff MatrixConstructing a Payoff Matrix1. 1. List advantages & disadvantages of using
substances, & advantages & disadvantages of not using substances in Payoff Matrix
2.2. Use all available information from functional assessment
3.3. Consider advantages & disadvantages from theclient’s perspective
4. 4. View different reasons listed as hypothesesabout maintaining factors, not establishedfacts; reasons may change as new informationemerges
5.5. If client is using, the pros of using & cons ofnot using should outweigh the pros of notusing and cons of using
Pay-Off MatrixPay-Off Matrix
Advantages
Disadvan-tages
Using Substances Not Using Substances
Common Advantages and Disadvantages of Using Common Advantages and Disadvantages of Using Substances and Not Using SubstancesSubstances and Not Using Substances
Using Substances Not Using Substances
Advantages Feels good Acceptance & friendship when using with peers Decreased social anxiety Feel "normal" when using with others Escape from belief one is a "failure" or has not
lived up to expectations Relief from depression or anxiety Reduction or distraction from hallucinations Help getting to sleep Improved attention & concentration Decreased medication side effects Something to look forward to Reduction in craving or withdrawal symptoms
Better relationships with significant others Stable & independent housing Improved control & stability of psychiatric
illness Financial stability & control over one's
money Stay out of jail/prison Minimized exposure to infectious diseases
& better management of medical illnesses Reduced exposure to trauma Improved ability to pursue goals & meet
major role obligations (worker, student,spouse, parent)
Better social relationships, includingintimate relationships, with people whoreally care
No physical dependence
Disadvantages Conflict with significant others Housing instability & homelessness Relapses & rehospitalizations Financial problems Legal problems Infectious diseases & other medical illnesses Increased exposure to trauma Inability to pursue goals & meet major role
obligations (worker, student, spouse, parent) Physical dependence leading to need for greater
amounts Sociopathic or criminal social network Lack of an intimate relationship Increased hallucinations or paranoia
Lack of positive feelings Awkwardness or peer pressure from friends
who use substances Social isolation because no friends who
don't use Social anxiety Feel "abnormal" because of stigma from
mental illness Confrontation with belief that one is a
failure Persistent depression or anxiety Distress due to hallucinations Poor attention & concentration Troubling medication side effects Nothing to do or look forward to Cravings or withdrawal symptoms
Examples of Interventions Based on Examples of Interventions Based on the Payoff Matrixthe Payoff Matrix
Using Substances Not Using Substances
Advantages Naltrexone Disulfiram
Contingent reinforcement Community reinforcement Motivational interviewing Decisional balance method Education about dual disorders Persuasion groups
Disadvantages Disulfiram Financial payeeship Conditional discharge from
psychiatric hospital Probation or parole condition
Skills training for socialcompetence
Identifying new social outlets Teaching skills for coping
with distressful symptoms Pharmacological treatment of
distressful symptoms Developing alternative
recreational activities Creating new & meaning
pursuits (e.g., work, school,parenting)
Teaching strategies for copingwith cravings
Treatment PlanningTreatment Planning
• GoalsGoals: : To determine which interventions are most likely to be effective and how to measure outcome
• StepsSteps
1. 1. Engage the client and significant others
2.2. Assess motivation to change
3.3. Select target behaviors, thoughts, emotions to change
4.4. Identify interventions to address targets: select at least 1 strategy to
enhance motivation & 1 strategy to address needs currently met by substance use
5.5. Choose measures to assess effects of intervention
Treatment BarriersTreatment Barriers
• Historical division of service and training
• Sequential and parallel treatments• Organizational and categorical funding
barriers in the public sector• Eligibility limits, benefit limits, and
payment limits in the private sector
Integrated TreatmentIntegrated Treatment
• Mental health and substance abuse treatmentDelivered concurrentlyBy the same team or group of
cliniciansWithin the same programThe burden of integration is on
the clinicians
Other Features of Dual Other Features of Dual Disorder ProgramsDisorder Programs
• Assertive outreach• Stage-wise treatment: engagement,
persuasion, active treatment, and relapse prevention
• Long-term commitment• Comprehensive treatment• Reduction of negative consequences
What are the Stages of What are the Stages of Treatment?Treatment?
1.1. Engagement, persuasion, active treatment, and relapse prevention
2.2. Not linear
3.3. Stage determines goals
4.4. Goals determine interventions
5.5. Multiple options at each stage
What Do We Do During What Do We Do During Engagement?Engagement?
• GoalGoal: : To establish a working alliance with the client
• Clinical StrategiesClinical Strategies1.1. Outreach
2.2. Practical assistance
3.3. Crisis intervention
4.4. Social network support
5.5. Legal constraints
What Do We Do During What Do We Do During Persuasion?Persuasion?
• GoalGoal: : To motivate the client to address substance abuse as a problem
• Clinical StrategiesClinical Strategies
1.1. Psychiatric stabilization
2.2. “Persuasion” groups
3.3. Family psychoeducation
4.4. Rehabilitation
5.5. Structured activity
6.6. Education
7.7. Motivational interviewing
What Do We Do During What Do We Do During Active Treatment?Active Treatment?
• Goal:Goal: To reduce client’s use/abuse of
substance
• Clinical StrategiesClinical Strategies1. 1. Self-monitoring
2. 2. Social skills training
3. 3. Social network interventions
4. 4. Self-help groups
5. 5. Substitute activities
6. 6. Close monitoring
7. 7. Cognitive-behavioral techniques to address:High risk situationsCravingMotives for substance use
SocializationPersistent symptomsPleasure enhancement
What Do We Do During What Do We Do During Relapse Prevention?Relapse Prevention?
• Goals:Goals: To maintain awareness of vulnerability and
expand recovery to other areas• Clinical StrategiesClinical Strategies
1.1. Self-help groups
2. 2. Cognitive-behavioral and supportive interventions to enhance functioning in:
Work, relationships, leisure activities, health, and quality of life
Relapse Prevention Relapse Prevention StrategiesStrategies
• Construction a relapse prevention plan:– Risky situations– Early warning signs– Immediate response– Social supports– Abstinence violation effect
Recovery MountainRecovery Mountain
• Combat demoralization related to relapses
• Reframe relapses as part of road to recovery
• Don’t loose sight of gains made between relapses
• Learning experience, modify relapse prevention plan
Stages of Substance Stages of Substance Abuse TreatmentAbuse Treatment
1. 1. Pre-engagementPre-engagement:: No contact with a counselor.
2. 2. EngagementEngagement:: Irregular contact with a counselor.
3. 3. Early PersuasionEarly Persuasion:: Regular contact with a counselor, but no reduction in substance abuse.
4. 4. Late PersuasionLate Persuasion: : Regular contact with a counselor and reduction in substance use (< 1 month).
5. 5. Early Active TreatmentEarly Active Treatment:: Reduction in substance use (> 1 month).
6. 6. Late Active TreatmentLate Active Treatment:: No abuse for 1-6 months.
7. 7. Relapse PreventionRelapse Prevention:: No abuse 6-12 months.
8. 8. RemissionRemission:: No abuse for over one year.
Research on Integrated Research on Integrated Treatment (IT)Treatment (IT)
• 26+ RCT or quasi-experimental studies of IT (reviewed by Drake et al., 2004)
• 3/4 studies of brief motivational interviewing interventions showed positive effects
• 6/7 studies found group intervention better than 12-step or standard care
Research on IT (Cont.)Research on IT (Cont.)
• Family intervention: no RCTs examining family treatment alone
• Comprehensive IT: 2 RCT & 1 quasi-exp. study favor comp. IT over treatment as usual
• Intensity: more intensive IT produces slightly better outcomes (e.g., Drake et al., 1998)
Drake et al. (1998)Drake et al. (1998)
• 203 clients (77% schizophrenia)• ACT vs. standard case management (SCM)
(both IT)• 3 year follow-up• ACT better than SCM in alcohol severity &
stage of treatment• No differences in hospitalization, symptoms,
quality of life
NH Dual Diagnosis StudyNH Dual Diagnosis Study
Proportion of Days in Stable Community Housing
0.7
0.8
0.9
1.0
Beginning 6 months 12 months 18 months 24 months 30 months 36 months
All DD Patients (N = 203) Patients in Recovery (N = 54)
1. Proportion of days in stable community housing (regular apartment or house, not in hospital, jail, homeless setting or doubling with friends or family) increased for all dual diagnosis clients.
2. They increased more rapidly for persons in recovery (no substance abuse for at least 6 months).
NH Dual Diagnosis StudyNH Dual Diagnosis Study
1. Percentage of persons hospitalized during each six months declined significantly for all clients.
2. It declined much more for those in recovery.
Percentage of Persons Hospitalized
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Beginning 6 months 12 months 18 months 24 months 30 months 36 months
All DD Patients (N = 203) Patients in Recovery (N = 54)
Fidelity to IT Model Fidelity to IT Model Improves OutcomeImproves Outcome
*** If current & subsequent points = 1 then the current score = 1Assessment Points Baseline 6 mo. 12 mo. 18 mo. 24 mo. 30 mo. 36 mo.Hi-Fidelity 0 19.67 26.23 29.51 37.7 42.62 55.74Low-Fidelity 0 3.85 3.85 7.69 7.69 15.38 15.38
Figure 1. Percent of Participants in Stable Remission for High-Fidelity ACT Programs (E ; n=61) vs. Low-Fidelity ACT Programs (G; n=26).
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Limitations of ResearchLimitations of Research
• Lack of standardization of treatments• No or limited fidelity assessment• No replication of program effects• Unclear or variable comparison
conditions
Avoiding the Avoiding the Blame/Demoralization Blame/Demoralization
TrapTrapDon’t blame the client for substance Don’t blame the client for substance
abuse or relapses because:abuse or relapses because: Substance abuse is a disorder for which
clients are no more responsible than their primary psychiatric symptoms
Clients with most severe substance abuse need professional help the most; many others improve spontaneously
Remember that the clients are doing the best they can
To avoid demoralizationTo avoid demoralization:: Remember: integrated treatment works in
the long run There is usually no obvious “best solution” Adopt a collaborative-empirical approach to
treatment View relapses as an inevitable part of the
recovery process Develop a case formulation based on a
functional analysis to guide treatment